Pictorial case study: Scalp folliculitis

A 45-year-old man presented with what he called ‘itchy spots' along his frontal hairline. He also had a few at the back.

The lesions had become sore and crusted recently due to scratching. On examination, small pustules were observed within the scalp. What is the diagnosis, differential diagnosis and management? 

Diagnosis and management
The man had scalp folliculitis. This is an inflammatory reaction of the hair follicles to bacteria such as Propionibacterium acnes, but in severe cases, also Staphylococcus aureus, yeasts or mites. It is also known as acne necrotica miliaris or Propionibacterium acnes folliculitis. It is most troublesome on the frontal hairline. The pustules can become sore and crusted.

The patient should be advised to wash his hair with a normal shampoo.

Antifungal agents such as ketoconazole are sometimes helpful. Topical or oral antibiotics should be considered, particularly in the long term.

Possible differential diagnoses

  • Acne cheloidalis nuchae.
  • Lichen planus.
  • Kerion.

Differential diagnosis

  • Acne cheloidalis nuchae
  • Also called folliculitis keloidalis or acne keloidalis.
  • Unusual skin condition affecting the nape of the neck.
  • More likely to affect adult dark-skinned individuals, particularly males with curly hair.
  • Itchy round pustules in the occiput.
  • Pustules become small scars that enlarge to become nodules, plaques and keloids.
  • The scars are hairless and can form a band along the hairline.


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